Dysphagia and Vocal Cord Paralysis after Anterior Cervical Disk Surgery
2004-2-25 R3 郭彥君
Anterior cervical diskectomy (and fusion)
1. Surgical indication
 Extrusion of disc and associated ostephytic out growth (spondylosis)
cervical radiculopathy and/or myelopathy
 Progressive neurologic deficit; static neurologic deficit with
radicular pain; persistent or recurrent arm pain that failed to response
with conservative treatment
2. Surgical technique
 1956 Cloward,1962 Smith and Robinson :anterior cervical
discketomy (ACD) with/without fusion
 Collar incision (midline –ant border of SCM) or vertical
incision(along ant border of SCM)
through platysma dissect middle layer of cervical fascia ,bypass
SCM & strap muscles
Blunt dissect carotid sheath and tracheoesophagus bundle
Incise prevertebral fascia ,establish exposed vertebra with spinal
needle and lateral radiograph, dissect longus colli m.
Apply Cloward retractor to expose ant cervical spine with carotid
sheath laterally and tracheoesophagus bundle medially
Remove osteophyte, disk with rongeur and drill under microscope
+/- post longitudinal lig. with curet to expose dura
Apply fusion graft
Close wound with/without drain
3. Complications:Dysphagia, vocal palsy, bleeding, esophageal
perforation, graft extrusion
Dysphagia
Occurrence: more than 80 % of patient undergoing ACD
Causes: Hematoma, deep neck infection, hardware complication
perforation of the pharyx, post operative adhesion between esophagus and
osteochondrosis of the vertebral bodies, vocal palsy
2002 Rajesh Bazaz et al:
Dysphagia decrease significantly by 6 months
Female gender and multiple surgical levels as risk factors
2003 Ahmed M.S.Soliman et al: associated only with age
1997 Ruth E.Martin et al:Videofluoroscopic analysis of 13 patient—
2/13 : (1)reduced pharyngeal wall movement, (2) impaired UES opening (3)
imcomplete epiglottic deflection (4) vallecular,pyriform sinus and post. Pharyngeal
wall residue :prevertebral swelling
3/13 : absent pharyngeal swallow: Sup laryngeal n. injury?
4/13: oral preparatory and oral stage deficit:hypoglossal n injury
compatible with operated vertebrae level
Vocal cord mobility impairment
Hoarsness:edema, hematoma, tearing of vocal cord, dislocation or
ankylosis of an arytenoids cartilage,recurrent laryngeal n. injury
Vocal cord palsy (due to recurrent laryngeal n. injury) :
Incidence:0%~16%
 Short-term intubation injury:
excessive cuff pressure in the subglottic space leading to compression
of RLN between cricoid and arytenoids cartilages(1983 Sean B.pepard
et al)
associated with surgery duration, age
During surgery: traumatic division, pinch, overstreching, post operative
edema of perineural tissues, RLN included in ligation of inf. thyroid a.,
direct long-standing pressure by retractors,trauma to cricoarytenoid joint
(Hans Heeneman et al ,1972)
Which side (of approach) is better to decrease injury of RLN?
Consideration of which side of approach:
the side of greatest disease , RLN, comfortable, thoracic duct, esophagus
The vulnerable RLN
Anotomy
An angle relative to sagittal plan inferiolaterally to superiomedially:
R’t :25.00+/- 4.70 ; L’t : 4.70 +/- 3.70 (1996 Nabil et al)
 Shorter course or R’t RLN: places it at greater risk(1995 Michael
J.Koriwchak et al)
 nonrecurrent RLN :R’t (1%) ; L’t (rare)
Higher incidence of R’t RLN injury: only the study of Robinson et al
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